Circumcision Surgery: What is It, Video, Procedure, Treatment

An Open Circumcision is the surgical removal of the foreskin covering the tip of the penis. A male may undergo a circumcision procedure for religious, social, medical, or cultural reasons. This procedure is most commonly done in newborn baby boys. 

Anatomy and Physiology of the Penis

The penis is a complex external organ used to urinate. It is also a part of the male reproductive system. It consists of several major structures:

1. Glans: the head of the penis is the sensitive structure at the end of the corpus (shaft).
2. Urethra: It is a tube inside the penis that runs from the bladder to the head of the penis. It is used for urination. 
3. Prepuce: also known as the foreskin, is a patch of skin that covers and protects the glans. Normally, when the penis gets hard the foreskin pulls back, and the tip is exposed. 

The penis is well supplied with blood vessels, and the shaft that contains the urethra and three tissue columns is wrapped in a band of connective tissue called the fascia and covered with the skin.  

Open circumcision is carried out for several medical or non-medical reasons. Some of the medical conditions that are treated by open circumcision include:

1. Phimosis: a condition where the foreskin is too tight to be pulled back over the head of the penis (glans).
2. Balanitis: a condition where the foreskin and head of the penis become inflamed and infected.
3. Paraphimosis: a condition where the foreskin can't be returned to its original position after being pulled back.
4. Balanitis xerotica obliterans: a condition that causes phimosis and in some cases, also affects the glans causing inflammation.
5. Cancer of the penis:  this is a rare type of cancer where a red patch, wart-like growth or ulcer appears on the end of the penis or under the foreskin.

Open circumcision is most commonly done in newborn baby boys. However, circumcision is also recommended for older boys or men to reduce the risk of certain penis conditions and sexually transmitted infections.

Usually, open circumcision is a daycare procedure and is carried out as an outpatient procedure. The surgery usually takes around 5 to 10 minutes. The procedure is generally performed under local anaesthesia by a specialized team of anaesthetists, surgeon or urologist. In the case of newborn baby boys, the procedure is performed by a paediatrician or obstetrician. Circumcision can be carried out by one of the following methods, depending on the case:

Conventional techniques

1. Dorsal slit technique: This technique prevents both phimosis and paraphimosis. In this procedure, the foreskin is separated from the head of the penis. With the help of forceps (a surgical instrument for holding something in place), both layers of the foreskin are cut off a few millimetres from the head of the penis.
2. Sleeve technique: In this procedure, the foreskin is retracted over the head of the penis, and a circumferential incision is made, usually distal to the corona (the proximal portion of the glans of the penis).
3. Forceps-guided method: In this method, the foreskin is separated and pulled out in front of the glans.

Modern techniques

1. Stapler circumcision: In this process, circumcision is performed using a circular stapling device. It is bloodless and the most efficient technique.
2. Laser circumcision: In this procedure, a laser is used to conduct the circumcision, as the laser has many advantages about precision and sealing of cut surfaces.

The patient may expect the following before or on the day of the surgery.

Before Open Circumcision Surgery

A few days before surgery, the surgeon will schedule an appointment with the patient for the following:

1. A complete physical check-up that also includes details about the patient's medical history.
2. The surgeon will explain the circumcision procedure and the benefits and risks of performing the surgery.
3. If the patient uses blood-thinning medications (e.g., aspirin), the doctor will ask the patient to stop taking those a few days before surgery.
4. The patient or his/her relative will be asked to sign a consent form.
5. The doctor will also discuss the medications that the patient currently uses. Patients should not forget to carry their routine medications during the pre-operative appointment.
6. Dietary habits before surgery
   1. The patient should avoid eating food or drinking fluids after midnight or six hours before surgery. This also applies to children undergoing the surgery.
   2. If circumcision is scheduled for a newborn boy, the parents should feed the baby with formula milk six hours or breast milk four hours before surgery.
   3. If a child older than one year is scheduled for circumcision, do not feed him with solid foods (including chewing gum and candy) or liquids (e.g., milk, fruit juice, and formula) after midnight.
   4. Children (including infants) should have only clear liquids (water, apple juice, grape juice) up to two hours before surgery.

On the day of Open Circumcision surgery

Once the patient (adult male or newborn boy) arrives at the hospital on the day of surgery, the healthcare staff will direct the next procedures:

1. The patient would be asked to sign an consent providing the approval to conduct the surgery.
2. The patient will be requested to remove any jewellery, contact lenses, or objects from the body.
3. The patient will also be asked to remove clothes and change them into a hospital gown.
4. The healthcare staff will provide the patient with an identification bracelet.
5. The healthcare staff will also record the patient's blood pressure, pulse rate, and blood pressure and then take the patient to the operating room.

A patient who has undergone open circumcision surgery can expect the following after the surgery:

The recovery process in the hospital

1. After completing the circumcision procedure, the patient will be transferred to a recovery room for observation.
2. Vital signs will be monitored (breathing, blood pressure, and pulse rate).
3. Wound dressing will also be done. 
4. The penis of the patient will look sore and swollen, but this will resolve within seven days post-surgery.
5. The patient would need to ask his friend or family member to drive him home after discharge.

Recovery process/expectation after hospital discharge

1. At home:
   1. For Newborn boy:
      1. Healing time is about one week.
      2. Place petroleum jelly (Vaseline) onto the area after changing the diaper. This helps protect the healing area.
      3. Some swelling and yellow crust formation around the site is normal.
   2. For Adults:
      1. The patient can have a bath 24 hours after the circumcision procedure. He should avoid using a hot tub or swimming pool for 14 days post-surgery.
      2. If the patient has a dressing, he should keep the dressing for two to three days post-surgery or as recommended by the surgeon.
      3. The patient should keep himself hydrated within the first 24 hours after surgery.
      4. The patient may apply an ice pack intermittently to the surgical site for about 20 minutes at a time on the first day after surgery.
      5. It may take around seven to ten days for the penis to recover. So, he may need to take bed rest for that period.
      6. Activities such as cycling, swimming, weight lifting, or other sports, that can damage the wound should be avoided by the patient.
      7. Sexual activity should be avoided for at least a month after the surgery.
      8. Wearing loose-fitting and comfortable clothes for two to three days after surgery will help prevent irritation of the penis.
      9. The tip of the penis should be cleaned at least once daily using water.
      10. Applying vaseline to the tip of the penis will help prevent the penis from sticking to the underwear.

2. Medications: 

   1. For three or four days after circumcision, the patient is likely to experience discomfort and swelling near the head of the penis. For this, the surgeon will prescribe some painkillers.

First follow-up appointment

1. The doctor will ask the patient to visit him around 2 to 3 weeks after the surgery for follow-up.
2. The doctor will examine the treated area to detect the recovery status.
3. The doctor will also prescribe some medications or ointments for properly healing the wound.

Open circumcision is a routine and safe procedure. This procedure has several benefits. Not only does it help in reducing the risk of penile diseases but it can also improve hygiene. Below mentioned are some of the benefits of open circumcision:

1. Reduces certain penis conditions such as paraphimosis and phimosis
2. Decreased risk of cervical cancer for partners
3. Decreased risk of Penile cancer
4. Reduces sexually transmitted infections
5. Reduces urinary tract infections

Open circumcision is a day-care procedure and is a safe procedure. As with any surgical procedure, some risks and complications are associated with the surgery. Some of the risks and complications of open circumcision are:

1. Bleeding
2. Infection
3. Reaction to anaesthesia
4. Pain
5. Cutting the foreskin too long or too short.
6. Irritation on the tip of the penis.
7. Meatitis (inflamed opening of the penis)

When is consultation with the doctor needed?

The patient can consult the doctor if the patient experiences any abnormal symptoms including:

1. Heavy bleeding
2. Infection
3. Severe pain
4. Irritation on the tip of the penis

For non-medical reasons, delayed circumcision does not have any negative consequences. However, in case of medical reasons, delayed circumcision can lead to the progression of the underlying conditions, like:

1. Untreated balanitis can lead to chronic (extended) inflammation (redness, soreness, and pain).
2. Similarly, long-standing phimosis can lead to permanent scarring, causing the constriction of the foreskin. It may also lead to dyspareunia (painful intercourse) in patients with diabetes.

The cost of open circumcision surgery ranges from ₹17,000 to ₹70,000. The cost varies based on the following factors:

1. Type of circumcision surgery planned to perform.
2. Condition of the foreskin (Phimosis, Paraphimosis, Balanitis).
3. Age of the patient.
4. Other medical conditions that the patient may have.
5. The type of hospital facility availed - individual room or shared.